Shedding light on hidden activity

Payment by results requires accurate recording of activity but, as Clive Evans reports, the system is far from flawless

The arrival of payment by results and the current national IT programme should be focusing NHS trusts' eyes on data collection systems, which need to accurately record activity. My recent research shows this might not be the case.

Trusts exist in a structure that supposedly defines its own data needs; at least that is true in the acute sector. But there is no real clarification of the data elements required to record activity away from the acute setting and this appears to be in contradiction with the shift of care from the acute sector to the community.

It may also explain why much of the activity that takes place in the community is outside the scope of payment by results.

This is an area that needs to be urgently addressed by the Department of Health, both in terms of ensuring payment by results can be rolled out to the community, and in assisting local service providers (and suppliers) in creating more generic systems that can be used in the community.

I want to focus specifically on the recording of outpatient activity. Within this narrow field there are inconsistencies across trusts that are leading them to miss and over-record activity.

Most outpatient activity takes place in the main outpatient departments. This activity is easy to record as the patient presents, their attendance is recorded, they leave and their outcomes are recorded. Although not foolproof (some activity is missed) there is a high rate of recording this kind of activity.

The real problems lie in activity that takes place outside these departments. This is namely on wards, at patients' homes and in accident and emergency departments.

Most readers will be familiar with ward attenders: patients attending a ward but not for admission and not occupying a bed. The ward attenders commissioning data set was discontinued recently but this activity still continues. As these patients are seeing a nurse or midwife they can be legitimately collected as outpatient activity and be included in the outpatient commissioning data set.

But how are trusts recording such data when these patients attend the ward and are seen by members of the medical staff? According to the NHS Data Dictionary these should be recorded as outpatient attendances. There is a widespread misconception that all patients attending a ward are ward attenders - this is not the case.

And if a patient sees a nurse and then needs to see clinical staff they should be recorded twice, as a ward attender and an outpatient attendance.

Finally there is another group of patients seen on wards that are hardly ever recorded as outpatients. These are patients admitted to a ward under one specialty but requiring input from another. For example, a patient admitted under a general surgeon following a head injury may require a neurosurgical input. Each time the neurosurgeon visits that patient on the ward it should be recorded as an outpatient attendance.

Although this is not a considerable amount of activity, there is an argument that such visits can and should be scheduled, and as such would come under the payment by results definition of outpatient activity attracting funds. Even if there was no financial incentive to collect this data, surely from a management perspective there is a need to record all this activity to get a better picture of just how trusts are using their resources.

Another area that is not well-recorded is where clinical staff visit patients at home. When such a visit does not attract a fee it can again be recorded as outpatient activity. There has been feedback from trusts that some do not record this data and others will add the data to an 'appropriate' clinic.

However, there was clear consensus that this type of activity should be recorded. Again it may well be limited, but surely trusts will want a record of it.

Finally we turn to an area that is never recorded, as confirmed by the NHS Data Dictionary. A patient attending accident and emergency who then requires an immediate second opinion from a non-A&E clinician is in effect being referred for an outpatient appointment and should be recorded as such.

To use the earlier example, a patient attending with a head injury will see A&E-based clinical staff. If they determine that a neurosurgical input is required they will contact the registrar for that specialty, who will then attend A&E and visit the patient. Such activity should be recorded as an outpatient attendance.

In some areas there is over-recording of outpatient activity. Outpatient activity is clearly defined in the NHS Data Dictionary; but other activity is not so clear. So some activities can be recorded in unintended ways. For example, some trusts will record day care activity using an outpatient clinic basis.

There may be a number of reasons for this. First their patient administration system may be limited and this is the only way of recording such activity. Second, the fact that day care activity is hard to define makes confusion easy. But using an outpatient system to collect data about day care cannot really record all activity if the patient sees more than a member of the clinical team.

So what is the way forward? Trusts will need to audit their activity collection systems to ensure all activity is recorded accurately to enable efficient monitoring of resource usage and to protect their payment by results income where appropriate.

The Department of Health needs to extend the rigour of acute activity definitions to cover all areas of NHS activity and ensure effective monitoring of resource use. Trusts must be confident that community activity is correctly reported.

Clive Evans is an independent consultant.